Perceptions Among Backcountry Skiers During the COVID-19 Pandemic: Avalanche Safety and Backcountry Habits of New and Established Skiers.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic impacted the ski industry worldwide by closing or limiting access to ski resorts. Subsequently, anecdotal reports of increased backcountry use emerged in the press, with concerns of inexperienced skiers causing or having problems in the backcountry. This study attempted to quantify this and identify motivations for new backcountry skiers. METHODS: Self-identified backcountry skiers and snowboarders (aged ≥18 y) in the United States and Canada completed an anonymous 29-question online survey distributed by regional avalanche centers, education providers, and skiing organizations (n=4792). Respondents were stratified by backcountry experience, defining "newcomers" who began backcountry skiing from 2019 to 2021, coincident with the COVID-19 pandemic. Percentages of ski days spent in the backcountry were compared before and during the COVID-19 pandemic using paired t-tests and across cohorts using repeated-measures analysis of variance. Avalanche education was compared using unpaired χ2 tests. RESULTS: Of established skiers, 81% noticed more people in the backcountry and 27% reported increasing their own use. Participants reported spending 17% (95% CI, 15.8-17.9) more of their days in the backcountry during the COVID-19 pandemic, with newcomers increasing their time spent by 36% and established skiers increasing their time spent by 13% (P<0.0001). Of newcomers, 27% cited the COVID-19 pandemic as motivation to enter the backcountry and 24% lacked formal avalanche education, which is significantly higher than the 14% of established skiers (P<0.0001). CONCLUSIONS: Influenced by factors related to COVID-19, reported backcountry use increased during the pandemic. Newcomers had a lower level of avalanche education and less confidence in evaluating terrain. Because 80% of participants were recruited from avalanche safety or education websites, this likely underestimates skiers lacking avalanche awareness or education and is further limited by the nature of online surveys.

Antibiotic overprescribing: Still a major concern.

Despite universal agreement that antibiotic overprescribing is a problem, the practice continues to vex us. Antibiotic use--whether appropriate or not--has been linked to rising rates of antimicrobial resistance, disruption of the gut microbiome leading to Clostridium difficile infections, allergic reactions, and increased health care costs. And yet, physicians continue to overprescribe this class of medication. A 2016 Centers for Disease Control and Prevention report estimates that at least 30% of antibiotics prescribed in US outpatient settings are unnecessary. Another report cites a slightly higher figure across a variety of health care settings. Pair these findings with the fact that there are currently few new drugs in development to target resistant bacteria, and you have the potential for a post-antibiotic era in which common infections could become lethal. Family practitioners are on the front lines of this battle. Here's what we can do now.

Urology and nephrology update: proteinuria and hematuria.

Proteinuria and hematuria can be benign or can be signs of more serious underlying pathology. The diagnostic evaluation should take into account the age of the patient as well as medical history, family history, concurrent symptoms, initial physical examination findings, and basic office laboratory test results. There are many tests to consider for proteinuria and hematuria. Routine screening for proteinuria is not recommended in the general population, but it is recommended for high-risk patients, such as those with diabetes and hypertension. Asymptomatic patients should not be screened for hematuria. Patients should be referred to a nephrology subspecialist if proteinuria is drug-resistant, if there is persistent hematuria with concomitant proteinuria, or if a renal biopsy is being considered. Patients should be referred to a urology subspecialist for abnormal genitourinary anatomy, trauma, stones, tumors, nonglomerular gross hematuria, or persistent microscopic hematuria.

Urology and nephrology update: anemia of chronic kidney disease.

Anemia is associated with chronic kidney disease (CKD) at all stages, and it is nearly universal among patients with stage 5 CKD. Nonetheless, anemia of CKD is a diagnosis of exclusion. When anemia is detected in a patient with CKD, etiologies other than CKD must be considered and ruled out. Iron deficiency also is common among patients with CKD, and iron replenishment improves the anemia and the response to erythropoiesis-stimulating agents. Current guidelines for managing anemia of CKD recommend a hemoglobin goal of 11 to 12 g/dL, but lower hemoglobin may be acceptable for asymptomatic patients. Some patients do not benefit from erythropoiesis-stimulating agents, or they lose their responsiveness to treatment and transfusions must be considered. Other agents are being investigated as management for anemia of CKD, with vitamin C (ascorbic acid) showing some promise.

Urology and nephrology update: bladder and kidney cancer.

It has been estimated that bladder and kidney cancers would be diagnosed in approximately 140,000 Americans in 2013, with approximately 30,000 dying from these cancers. Urinary tract cancers affect men more commonly than they do women, and the median age at diagnosis is 65 years. Major risk factors for these cancers include tobacco smoking, certain chemical exposures, family history, age, and obesity. Unexplained hematuria in adults should be evaluated to exclude bladder and kidney cancer. Staging of bladder and kidney cancer should be based on the TNM staging system, which, along with tumor grade, provides important treatment and prognostic information. Urothelial cell carcinoma is the most common type of bladder cancer; it also can occur in the kidneys or ureters. Renal cell carcinoma is the most common type of kidney cancer. Treatment options for bladder cancer vary widely, depending on the grade of the cancer. Early non-muscle-invasive bladder cancer may be removed cystoscopically and/or treated with intravesical immunotherapy or chemotherapy, whereas patients with muscle-invasive bladder tumors typically require surgery. Management of kidney cancer is almost always surgical, unless the patient is too ill to undergo surgery or chooses palliative care.

Urology and nephrology update: recurrent urinary tract infection.

Urinary tract infections (UTIs) are common among children and adults, with the greatest prevalence in women. One-half of all women will develop a UTI at some point. Approximately one-third of children with UTIs develop recurrent infections, and because recurrent UTIs have been thought to lead to renal scarring, practice has focused on identifying patients at risk of UTIs and limiting recurrence. It is difficult to determine which children are at risk of renal damage, and the benefits of antibiotics or surgery in preventing recurrent UTIs in children are unclear. Therefore, recent guidelines have taken a less aggressive approach to the prevention of recurrent UTIs in children. Recurrent UTIs also may be an issue for women. Sexual intercourse is a major risk factor, and postcoital prophylactic antibiotic treatment has been shown to be effective. Immediate antibiotic treatment of UTI symptoms also has shown efficacy. Although cranberry supplements or juice may be effective, the benefit of other commonly recommended treatments, such as frequent or postcoital voiding, increased fluid consumption, and avoiding bubble baths, has not been shown.

Altitude illness: risk factors, prevention, presentation, and treatment.

Altitude illness affects 25 to 85 percent of travelers to high altitudes, depending on their rate of ascent, home altitude, individual susceptibility, and other risk factors. Acute mountain sickness is the most common presentation of altitude illness and typically causes headache and malaise within six to 12 hours of gaining altitude. It may progress to high-altitude cerebral edema in some persons. Onset is heralded by worsening symptoms of acute mountain sickness, progressing to ataxia and eventually to coma and death if not treated. High-altitude pulmonary edema is uncommon, but is the leading cause of altitude illness-related death. It may appear in otherwise healthy persons and may progress rapidly with cough, dyspnea, and frothy sputum. Slow ascent is the most important measure to prevent the onset of altitude illness. If this is not possible, or if symptoms occur despite slow ascent, acetazolamide or dexamethasone may be used for prophylaxis or treatment of acute mountain sickness. Descent is mandatory for all persons with high-altitude cerebral or pulmonary edema. Patients with stable coronary and pulmonary disease may travel to high altitudes but are at risk of exacerbation of these illnesses. Medical management is prudent in these patients.

Bibliotherapy as a treatment for depression in primary care.

This study was designed to determine whether a physician-delivered bibliotherapy prescription would compare favorably with the prevailing usual care treatment for depression in primary care (that often involves medication) and potentially offer an alternative. Six family physicians were trained to write and deliver prescriptions for cognitive-behavioral bibliotherapy. Thirty-eight patients were randomly assigned to receive either usual care or a behavioral prescription to read the self-help book, Feeling Good (Burns, D. D. (1999). Feeling good: The new mood therapy. New York: HarperCollins). The treatment groups did not differ in terms of overall outcome variables. Patients in both treatment groups reported statistically significant decreases in depression symptoms, decreases in dysfunctional attitudes, and increases in quality of life. Although not statistically significant, the mean net medical expenses in the behavioral prescription group were substantially less. This study provided empirical evidence that a behavioral prescription for Feeling Good may be as effective as standard care, which commonly involves an antidepressant prescription.

Pain in the quiet (not red) eye.

Although eye pain is often accompanied by redness or injection, pain can also occur with a quiet eye. Pain in a quiet eye can be the first sign of a vision-threatening condition, a more benign ophthalmologic condition, or a nonophthalmologic condition. Acute narrow-angle glaucoma is an emergent vision-threatening condition that requires immediate treatment and referral to an ophthalmologist. Although most nonophthalmologic conditions that cause eye pain do not need immediate treatment, giant cell (temporal) arteritis requires urgent treatment with corticosteroids. Other vascular conditions, such as carotid artery disease, thrombosis of the cavernous sinus, and transient ischemic attack or stroke, rarely cause eye pain but must be considered. Pain may also be referred from the sinuses or from neurologic conditions, such as trigeminal neuralgia, migraine and cluster headaches, and increased intracranial pressure. The differential diagnosis of eye pain in the quiet eye is extensive, necessitating a systematic and thorough approach.

Injuries associated with whitewater rafting and kayaking.

Whitewater rafting and kayaking are growing exponentially in popularity, with almost 10 million rafters and 2 to 3 million kayakers, yet little has been published concerning the safety or hazards of these activities. This article reviews the demographics of such injuries and the types of injuries commonly encountered. Fortunately, fatalities are uncommon in these activities, with rafting and kayaking fatalities occurring at a rate of 0.55 and 2.9 per 100000 user days, respectively. Injury rates for kayaking and rafting are 3 to 6 and 0.26 to 2.1 per 100000 boating days, respectively. Acute injuries in kayaking are usually due to the transferred force of the water on the upper extremity, most often the shoulder, or the impact on an object while "swimming." Acute rafting injuries are more often due to contact with another rafter's paddle or other equipment; the next most common injury is the rafter hitting an object while "swimming." Chronic injuries are very uncommon in rafting but account for 25% to 40% of all kayaking injuries and are most often either shoulder or wrist complaints.